(718) 732-0222
(718) 732-0222
ORTHOPEDICS
PATIENT LAST NAME
PATIENT FULL FIRST NAME
CLINICAL INDICATIONS/SIGNS/SYMPTOMS (NOT RULE/OUT):
TODAY'S DATE ICD-10:
DATE OF BIRTH
PHYSICIAN SIGNATURE (REQUIRED) PHYSICIAN NAME (PRINTED OR STAMPED)
PHYSICIAN ADDRESS
patients:
call to make an appointment
take a cell phone photo of this form and text or email it to rx@
MRI (magnetic resonance imaging)
CT (computed tomography)
X-RAY
16 MRI Chest: No IV Contrast 71550
Pectoralis Tear
SC Joint Pain
Sternal Trauma
Brachial Plexus
29 MRI Upper Extremity Joint: No IV Contrast 73221
R L Shoulder Indications:
Fracture
R L Elbow
Joint Pain
Labral Tear
R L Wrist
Arthritis
Ligament Tear
Bursitis
Tendon Tear
30 MRI Upper Extremity Joint: Pre + Post IV Contrast 73223
R L Shoulder Indications:
Infection
R L Elbow
Abscess
Mass
R L Wrist
Tumor
Osteomyelitis
31 MR Arthrogram Upper Extremity Joint:
R L Shoulder Arthrogram 73222/23350
R L Elbow Arthrogram 73222/24220
84 CT Cervical Spine: No IV Contrast 72125
85 CT Thoracic Spine: No IV Contrast 72128
86 CT Lumbar Spine: No IV Contrast 72131
87 CT R L Upper Extremity: No IV Contrast 73200
Fracture Pain
Clavicle Shoulder Scapula
Humerus Elbow Forearm
Wrist Hand Fingers
88 CT R L Upper Extremity: Post IV Contrast Only 73201
Tumor Infection
Clavicle Shoulder Scapula
Humerus Elbow Forearm
Wrist Hand Fingers
120 X-Ray Head
Skull Nasal Bones Facial Bones
122 X-Ray Chest
Chest Right Ribs Left Ribs
Sinus Orbits For Foreign Body Orbits-Complete
Bilateral Ribs Sternum Sternoclavicular Joints
124 X-Ray Spine
Cervical AP, LAT, APOM
Add Obliques Add Lateral Flexion/Extension Add AP Right & Left Lateral Bending
R L Wrist Arthrogram 73222/25246
32 MRI Upper Extremity Non-Joint: No IV Contrast 73218
R L Humerus
Indications:
R L Forearm
Fracture
89 CT Arthrogram R L Upper Extremity
Shoulder Elbow
Wrist
Other: ________
73201/23350 73201/24220 73201/25246
Thoracic AP, LAT Add Obliques
Lumbar AP, LAT Obtain Lumbar Films Upright
R L Hand
Muscle Tear
90 CT R L Lower Extremity: No IV Contrast 73700
R L Finger Specify#:
Tendon Tear
Hip
Tib/Fib
33 MRI Upper Extremity Non-Joint: Pre + Post IV Contrast 73220 Fracture Femur
Ankle
R L Humerus
Indications: Pain
Knee
Foot
R L Forearm
Tumor
Knee W/ Patella Tracking Toes
R L Hand
Infection
Indicate Degrees:________
R L Finger Specify#:
Osteomyelitis
34 MRI Lower Extremity Joint: No IV Contrast 73721
R L Hip Indications:
Meniscal Tear
R L Knee Pain
Ligament Tear
R L Ankle Fracture
Cartilage Tear
91 CT R L Lower Extremity: Post IV Contrast Only 73701
Tumor Infection
Hip Femur Knee
Tib/Fib Ankle
Foot Toes
Internal Derangement Instability
92 CT Arthrogram R L Lower Extremity
Labral Tear
35 MRI Lower Extremity Joint: Pre + Post IV Contrast 73723
R L Hip Indications:
Osteomyelitis
Hip
Knee
Ankle Other: ________
73701/27093 73701/27370 73701/27648
R L Knee
Tumor
Cellulitis
R L Ankle Infection
36 MR Arthrogram Lower Extremity Joint
78 CT Pelvis: No Oral, No IV Contrast 72192
Bony Pelvis
Sacrum/Coccyx
R L Hip Arthrogram 73722/27093
SI Joints
R L Knee Arthrogram 73722/27369
R L Ankle Arthrogram 73722/27648
37 MRI Lower Extremity Non-Joint: No IV Contrast 73718
R L Femur/Thigh
Indications:
83 CTA Runoff: No Oral, Post IV Contrast Only 75635
Claudication
Occlusion
Stenosis
R L Tib/Fib / Calf R L Foot
Fracture Muscle Tear
93 Other
Add Obliques Add Lateral Flexion/Extension Add AP Bending To R & L
Sacrum/Coccyx
Scoliosis Series (Always Upright)
125 X-Ray Extremities
R L BILATERAL
ACSSHFihc/lnaaCaognvpuJedioculrdilnleSaetprsecifyHEFWB#oloub:rrnmioesetaweArrmugse
Pelvis
Weight-Bearing
Hip
Weight-Bearing
Femur
Knee
Weight-Bearing
Tibia/Fibula
Ankle
Calcaneus
Foot
Weight-Bearing
Toe Specify #:
NUCLEAR MEDICINE R L Toe Specify#:
Tendon Tear
38 MRI Lower Extremity Non-Joint: Pre + Post IV Contrast 73720
126 Skeletal Xray Survey
R L Femur/Thigh R L Tib/Fib / Calf
Indications: Tumor
220 Bone Scan?Whole Body 78306
127 Other
R L Foot R L Toe Specify#:
Soft Tissue Mass Osteomyelitis
221 Bone Scan 3 Phase 78315 Region
DEXA
27 MRI Pelvis: No IV Contrast 72195
Pelvic Pain
SI Joint Pain
222 Bone Scan Spect 78320 Region
Sacral/Coccyx Pain
39 MRA ABD/PEL and Lower Extremity Runoff: Post IV Contrast
223 Other
160 Dexa Hips, Lumbar, Wrist 77080 161 Dexa Hips, Lumbar 77080 162 Dexa with LVA 77085
74185, 72198, 73725, 73725 Claudication
Indications:
40 MRI Cervical Spine: No IV Contrast 72141
Neck Pain
Disc Herniation
ULTRASOUND
INTERVENTIONAL
Numbness
Trauma
Radiculopathy
41 MRI Cervical Spine: Pre + Post IV Contrast 72156
Syrinx
Tumor/Mass
108 Extremity Doppler Ultrasound
Venous for DVT Upper Lower Bilateral 93970 Right 93971 Left 93971
176 MSK Fluoro-Guided RT LT Shoulder Aspiration Injection 77002/20610
Discitis
Osteomyelitis
Multiple Sclerosis
42 MRI Thoracic Spine: No IV Contrast 72146
Pain
Trauma
Disc Herniation
Compression Fracture
Radiculopathy
43 MRI Thoracic Spine: Pre + Post IV Contrast 72157
Syrinx
Tumor/Mass
Pain Edema Difficulty walking Shortness of breath
Arterial Upper Bilateral 93930 Right 93931 Left 93931
Elbow Wrist Hip Knee Ankle Foot
Aspiration Aspiration Aspiration Aspiration Aspiration Aspiration
Injection 77002/20605 Injection 77002/20605 Injection 77002/20610 Injection 77002/20610 Injection 77002/20605 Injection 77002/20605
Discitis
Osteomyelitis
Multiple Sclerosis
44 MRI Lumbar Spine: No IV Contrast 72148
Lower Back Pain
Disc Herniation
Numbness
Radiculopathy
Trauma
Leg Pain
45 MRI Lumbar Spine: Pre + Post IV Contrast 72158
Discitis
Tumor/Mass
Post-Op
Arterial Lower Bilateral 93925 Right 93926 Atherosclerosis Claudication Pelvic Pain
109 US Extremity 76881 R
Body Part:
Left 93926
L
177 MSK Shoulder Elbow Wrist Hip Knee
Ultrasound-Guided RT LT Aspiration Injection 20611 Aspiration Injection 20606 Aspiration Injection 20611 Ganglion 20612 Aspiration Injection 20611 Aspiration Injection 20611
46 Other
119 Other
Ankle Aspiration Injection 20606
178 Other
RAD
(718) 732-0222
TOWN
ADDRESS
TRANSIT
FAX NUMBER
MANHATTAN HARLEM
324W 125th St, 10027
BRONX PARKCHESTER 1888 Westchester Ave, 10472
BROOKLYN COBBLE HILL 205 Smith Street, 11201
CROWN HTS 1128 Eastern Pkwy, 11213
QUEENS BAYSIDE
213-02 Northern Blvd, 11361
ELMHURST LAURELTON OZONE PARK
88-12 Queens Blvd, 11373 231-35 Merrick Blvd, 11413 102-34 Atlantic Ave, 11416
ACBD
(718) 696-0767
M3, M10, M100, M101, M60, BX15
6 Q44, BX4, BX4A, BX36, BX39 (718) 696-0193
FG
B57
(718) 684-7425
2 3 4 B14, B17, B46 (718) 684-7438
Q12, Q13, Q27, Q31, QM3, n20, n20G (718) 684-7423
RM Q5 Q24
Q59, Q60
(718) 684-7427 (718) 684-7421 (718) 684-7429
95 95
BRONX 895
Yankee Stadium
1888 WESTCHESTER AVE PARKCHESTER
695
324W 125TH STREET HARLEM
278 SOUNDVIEW
295 678
THROGS NECK
678 278
MANHATTAN DR Dri rand Central Pkwy
ve F
WHITESTONE COLLEGE POINT
Cross Isla
907 NORTHERN BLVD GREAT NECK
nd Pkwy
278
ASTORIA
La Guardia Airport
Grand Central Pkwy
678
FLUSHING
213-02 NORTHERN BLVD
MURRAY HILL
BAYSIDE
LITTLE NECK
JACKSON
HEIGHTS
678
WOODSIDE
295 495
25 495
SUNNYSIDE
278 495
GREENPOINT
88-12 QUEENS BLVD
25 ELMHURST
295 495
FRESH MEADOWS
495
REGO PARK
FOREST MIDDLE VILLAGE HILLS
QUEENS
25
C
ross Island Pkwy
G
25
1390 HEMPSTEAD TPKE ELMONT
WILLIAMSBURG
RIDGEWOOD
278
205 SMITH STREET COBBLE HILL
BUSHWICK
BEDFORD-STUYVESANT
RED HOOK
1128 EASTERN PKWY CROWN HEIGHTS
678 25
102-34 ATLANTIC AVE OZONE PARK
QUEENS VILLAGE
231-35 MERRICK BLVD
ST ALBANS
LAURELTON
278
PARK SLOPE
27
BROOKLYN
BROWNSVILLE EAST NEW YORK
Belt Pkwy
HOWARD BEACH
678
Belt Pkwy SPRINGFIELD
GARDENS ROSEDALE
John F. Kennedy International Airport
VALLEY STREAM
EAST FLATBUSH CANARSIE
BOROUGH PARK
FLATLANDS
MIDWOOD
625 ROCKAWAY TPKE LAWRENCE
HEWLETT WOODMERE
INWOOD
WOODSBURGH
CEDARHURST
6/19
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